Disturbance of Self-Evidence and Delusion

Abstract: Psychopathologically we study the process from the disturbance of self-evidence to the formation of delusions. When delusions arise on the basis of the disturbance of self-evidence, this disturbance impairs the way of judgment. We present a case of schizophrenia in which the unlimited questions about grounds make it impossible for the patient to establish the self-evident as itself and to judge inductively. The formation of delusions is the psychopathological extrication from the impairment of the inductive judgment. In the formation of delusions on the basis of the disturbance of self-evidence, we can observe the process from the weakening to the substantiation toward the outside of the transcendental organization.     

Developmental consideration on the loss of self-evidence (natürlichen Selbstverst?ndlichkeit) in pervasive developmental disorders]

The "loss of self-evidence" has been noted by many, particularly in our country, as a fundamental dysfunction in schizophrenia. Recent recognition of this "loss of self-evidence" in personality disorders such as borderline cases, and developmental disorders such as autism and Asperger's syndrome is focusing renewed interest on this perspective. It is possible that investigation into this "loss of self-evidence" noted in the pervasive developmental disorders may provide clues into the process of its development and acquisition. This paper takes up the issue of "loss of self-evidence" illustrated through the treatment process of 2 patients (female, adulthood autism, adolescent Asperger's syndrome) the author has treated. The psychopathology of the "loss of self-evidence" seen in the pervasive developmental disorders is discussed through these cases in terms of development from the standpoint of clinical intervention for relationship disturbance. The conclusions are as follows. First, the grave psychopathology pertaining to "self-evidence" in the adult autism and adolescent Asperger's syndrome cases is discussed, wherein difficulty in controlling one's action by one's own will giving rise to serious estrangement between experience and consciousness is noted as the pathology held in common by the two. Next, through examination of the normal acquisition process of words and language, it is shown that the essence of the language disorder seen in pervasive developmental disorders lies in the acquisition of meanings of objects being based upon the absence of common experience between subject and caregiver. As such, words representing meaning and content as we see them are imprinted on such individuals, never harmonizing with their own experiential world, giving rise to serious estrangement between their experience and consciousness. Third, sharing what the child is focusing upon in the outer world and how he/she is relating to it in their experiential world, and approaching them with words appropriate to their interpretation, is pointed out as being of critical importance in the self-evidence. In support of this, it is asserted that the establishment of affective communication characterized by mutual resonance of body and affect, and the development of communication upon this basis will, for the first time, enable transmission of culture to such individuals in favorable form, emphasizing the exceptional importance of attachment formation (amae) as being the key to this process.     

Cognitive insight and psychotic disorder: the impact of active delusions

While several studies have determined the Beck Cognitive Insight Scale (BCIS; [Beck, A.T., Baruch, E., Balter, J.M., Steer, R.A., Warman, D.M., 2004. A new instrument for measuring insight: The Beck Cognitive Insight Scale. Schizophr. Res. 68, 319–329] is a useful measure of cognitive insight, a number of questions have remained unanswered. While individuals with psychotic disorders have been shown to have impaired cognitive insight compared to a psychiatric comparison group, it has remained unclear how the cognitive insight of individuals with psychotic disorders compares to healthy individuals. Further, as previous studies have classified participants based on diagnostic classification, it has remained unknown if individuals with delusions and individuals with psychotic disorders without active delusions score differently on this measure. To examine these questions, we assessed the cognitive insight of healthy individuals and individuals with psychotic disorders, both with and without active delusions. Results indicated that individuals with psychotic disorders had impaired cognitive insight relative to healthy controls (p = .005), though individuals with active delusions and individuals with psychotic disorders without delusions had impairments in different domains. Individuals with delusions were overly confident in their own judgment relative to healthy controls and those without delusions (p = .011), though their self-reflectiveness was the same as normal controls. Individuals without delusions reported low self-reflectiveness relative to healthy controls and individuals with delusions (p = .004), though they were not overconfident in their judgment. These results are discussed in terms of existing research on cognitive insight, decision making, and psychosis.     

Gaze direction determination in schizophrenia

It has been proposed that an impairment in gaze determination is responsible for the paranoid symptoms reported in schizophrenia. To address this, we examined the gaze discrimination system in schizophrenia. Thirty-two patients suffering from schizophrenia (20 patients with persecutory delusions and 12 patients without such delusions) were compared to 32 control subjects on two specific tasks. In the first task, the subjects had to determine whether 130 portraits were looking right or left. In the second task the subjects were asked to determine whether or not 130 portraits were looking at them.The absolute threshold of difference used to investigate the influence of instruction on gaze discrimination did not show any difference between patients with schizophrenia, whatever paranoid or not, and control subjects. Paranoid patients, as well as controls, displayed a significantly finer discrimination threshold in the right vs. left judgment than in the self vs. non-self judgment. Subjects with schizophrenia were able to discriminate gaze direction in the two tasks, but they took significantly more time in the task requiring to determine the presence or the absence of a mutual gaze contact than in the other one, whereas controls took the same duration to elicit both tasks. These data are consistent with those reporting that perceptual abilities are spared in schizophrenia while delusions are related to an impairment of a higher level of analysis.     

Defective inhibition of dream event memory formation: a hypothesized mechanism in the onset and progression of symptoms of schizophrenia

An average person normally spends at least 90 min to 2 h per night dreaming. Nevertheless, memories of dream events are not retrieved while awake unless the person awoke shortly after a dream. It is hypothesized here that schizophrenic delusions initially arise because a system that normally inhibits the formation of memories of dream events is defective. Therefore, memories of dream events or fragments would be occasionally made and placed in the normal memory store. The only reason that we really know anything happened to us in the past is that we have a memory of it, and having a memory of an event is sufficient to really believe it. Therefore, the schizophrenic would believe that the dream events actually happened. It is proposed that this is the basis of primary delusions. Because memories are represented by strengthened neural connections there will be an accumulation of connections that do not correspond to reality. This accumulation may account for other symptoms of schizophrenia such as thought disorder, loosening of associations, and hallucinations. The brain trying to draw conclusions from several memories may be the basis of secondary delusions. Evidence is presented for the ideas that primary delusions are due to memories of dream events, that a substance, with vasotocin-like bioactivity, is released in the brain during dreaming and inhibits memory formation, that the lateral habenula is a brain area involved in vasotocin actions and is affected by neuroleptics, and that brain mechanisms involved in vasotocin actions show pathological alterations in schizophrenia.     

Organic brain syndrome in three cases of acquired immune deficiency syndrome

A triad of psychiatric symptoms involving mood disturbance, thought disorder with grandiose delusions, and severe memory deficits is described for three male homosexual patients suffering from acquired immume deficiency syndrome. The evidence suggests that the last two of these symptoms are inexplicable on the basis of previous psychiatric history or as a reaction to medical illness. Rather, an organic brain syndrome may be part of the natural history of AIDS for some patients.     

Psychopathology and treatment responsiveness of patients with first-episode schizophrenia

One hundred and four male patients hospitalized for the first time with the diagnosis of first-episode schizophrenia were comprehensively assessed on admission and discharge. Psychopathology, treatment response, and remission rates were evaluated (based on the Positive and Negative Syndrome Scale (PANSS), severity of symptoms only). On admission, the most frequently observed symptoms were lack of judgment and insight (87.6%), suspiciousness/feelings of persecution (82.3%), delusions (77%), poor attention (70%), disturbance of volition (65.4%), conceptual disorganization (64.7%), and active social avoidance (64%). Except for delusions and hallucinations, the positive items of the PANSS correlated significantly with negative symptoms, and conceptual disorganization correlated with the greatest number of negative symptoms. Individual negative symptoms were present in about half the patients. At discharge, the most frequent symptoms were again lack of judgment and insight (in 55.7%), and for negative symptoms they were blunted affect (22.1%), emotional withdrawal (21.2%), and passive/apathetic social withdrawal (19.5%). The positive symptoms of suspiciousness/feelings of persecution and grandiosity persisted in 20.6% of patients. On average, all symptoms were significantly reduced 44 days after admission. The negative symptoms improved less, compared with the positive ones. At discharge there was a high rate of responders (response defined as minimal 30% reduction of total PANSS): 73% and 74% of patients fulfilled the criteria for remission. On admission, the responders (n = 76) had significantly higher scores of most symptoms, both positive and negative ones than nonresponders (n = 28).     

A study of premorbid personality and behavioural and psychological symptoms of dementia in nursing home residents

OBJECTIVE: to investigate the relationship between pre-morbid personality and behavioural and psychological symptoms of dementia (BPSD). METHODS: we studied 58 subjects with dementia and depression and/or psychosis residing in 11 Sydney nursing homes cross-sectionally. Informal caregivers completed ratings of residents' pre-morbid personality on the NEP Five-Factor Inventory (NEO-FFI). Information on BPSD was obtained using the BEHAVE-AD. RESULTS: higher neuroticism was predictive of delusions; higher agreeableness of hallucinations, aggressiveness, affective disturbance and overall behavioural disturbance; and higher openness of affective disorder. CONCLUSION: our findings are inconsistent with previous research and clinical experience. Prospective studies are needed to clarify the association between personality and behavioural disturbance in dementia.     

The relation between emotional awareness and hallucinations and delusions in acute psychiatric inpatients

BACKGROUND: Although negative affect has been frequently implicated in the formation of cognitive and perceptual disturbances ranging from odd perceptions and beliefs to delusions and hallucinations it represents only one of the many aspects of emotional disturbances that may contribute to psychopathology. Surprisingly, no past research has examined in a psychiatric sample whether levels of cognitive-perceptual symptoms are associated with levels of emotional awareness (i.e., attention to emotion and clarity of emotion). In the present study we examined, in an acute psychiatric inpatient sample, the relations between emotional awareness and the severity of delusions and hallucinations. METHOD: Two groups were included: 34 schizophrenia and schizophrenia spectrum disordered inpatients and 30 mood and substance use disordered inpatients. Patients were assessed on emotional awareness (attention to emotion and emotional clarity) and severity of psychiatric symptomatology. RESULTS: We found that lower levels of emotional clarity were associated with more severe hallucination ratings in both groups of patients. Among schizophrenia spectrum patients, lower levels of attention to emotion were also associated with more severe hallucination ratings. Among mood/substance disorder participants, higher levels of attention to emotion were associated with more severe delusion ratings, whereas the opposite pattern was found among schizophrenia spectrum participants. CONCLUSIONS: Consistent with the results of past research using college and community samples, we found that diminished emotional clarity is associated with elevated levels of hallucinations in both mood disorder/substance abuse and schizophrenia spectrum inpatients. We also found that greater attention to emotion was associated with more severe delusions, though only among the mood disorder/substance use group. The present research findings support the role of emotional awareness in hallucination formation and suggest that the factors that contribute to delusions in schizophrenia spectrum patients differ, in part, from the factors that contribute to delusion formation in other groups of individuals.     

Agitation and other noncognitive abnormalities in Alzheimer's disease.

Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms.     

Neuroimaging of delusions in Alzheimer's disease

MEDLINE, Embase and PsycINFO were searched using the keywords "imaging", "neuroimaging", "CT", "MRI", "PET", "SPECT", "Alzheimer's", "dementia", "delusions" and "psychosis" to find studies specifically assessing or reporting on neuroimaging of delusions in Alzheimer's Dementia (AD), separate from hallucinations or psychosis in general in AD. Twenty-five studies were found meeting criteria and are included in this review which reports on structural, regional perfusion, metabolic and receptor binding imaging modalities assessing delusions as a whole, as well as persecutory and misidentification delusional subtypes. The majority of studies implicate right-sided pathology, primarily frontal lobe. Left-frontal predominance and release, secondary to right-sided pathology, may create a hyperinferential state resulting in the formation of delusions. This perturbation and imbalance of normal networks is associated with delusional phenomenology. Temporal lobe structures are also important in misidentification syndromes, which have a different natural history than paranoid delusions. Consistent with the neuropathological and genetic literature, neuroimaging has shown that paranoid versus misidentification delusions are associated with different phenomenology and different neural substrates. Delusional subtype is an important factor in understanding the neurobiological underpinnings of delusions in dementia. We also discuss methodological issues related to neuroimaging of delusions in AD.     

Impaired semantic memory in the formation and maintenance of delusions post-traumatic brain injury: a new cognitive model of delusions

This paper proposes a new cognitive model to explain the aetiology of delusions irrespective of diagnosis and/or phenomenology. The model hypothesises the influence of two processes in the formation and maintenance of delusions; (i) impaired perceptual abilities, particularly affect perception, which fosters the encoding of (ii) idiosyncratic semantic memories, especially those with an affective/self-referential valence. Previous research has established that schizophrenia patients with delusions have impaired semantic memory function. In the current paper we sought to provide evidence for (ii) abnormal semantic processing in persons with delusions with an alternative aetiology. Performance of four cases with a significant delusion post a traumatic brain injury was examined on a broad range of semantic memory tests. Overall semantic processing was impaired in the four cases relative to a normative healthy control sample. Cases performed better on tasks which required categorical identification, relative to the novel production of semantic information, which was poor in all four of the cases. These data offer preliminary evidence for our hypothesis of impaired semantic processing in persons with delusions. Findings will need to be empirically verified in larger sample groups and in those with alternative aetiologies.     

Fictionality of Schizophrenic Delusions

Abstract: A state in which the phenomena of the surrounding world are transformed into a set of symbols that transmit indefinite meanings is thought to provide the circumstances under which delusions arise. The surrounding world is interpreted as a written text, and when the schizophrenic reads this and attempts to construct a coherent fictional account of it, a process of delusion formation takes place, and this process corresponds symptomatologically to a delusional system. If delusions are considered in comparison with fictions, in particular fantastic fictions, areas are found in the paranoid patient's mental processes where contingency is left out, and for that reason it is not possible for the delusional account to be satisfactorily completed.     

Fictionality of schizophrenic delusions

A state in which the phenomena of the surrounding world are transformed into a set of symbols that transmit indefinite meanings is thought to provide the circumstances under which delusions arise. The surrounding world is interpreted as a written text, and when the schizophrenic reads this and attempts to construct a coherent fictional account of it, a process of delusion formation takes place, and this process corresponds symptomatologically to a delusional system. If delusions are considered in comparison with fictions, in particular fantastic fictions, areas are found in the paranoid patient's mental processes where contingency is left out, and for that reason it is not possible for the delusional account to be satisfactorily completed.     

Association of impaired reality processing with psychotic symptoms in schizophrenia

Reality evaluation (i.e., the discrimination of things existing outside of oneself and figments of others' imagination) may be impaired in patients with schizophrenia, and impairment in reality evaluation may be related to psychotic symptoms such as hallucinations and delusions. In this study, we investigated the nature of impairment of reality processing and its relationship with hallucinations and delusions in schizophrenia. Twenty-six patients with schizophrenia and 25 healthy controls completed the reality evaluation task, in which subjects judged whether scenes in a series of drawings were real or unreal and whether they were familiar or novel. The patient group exhibited significantly lower accuracy in reality evaluation than the control group, and lower accuracy in the patient group was related to more severe hallucinations and delusions. These findings provide preliminary evidence that impaired reality evaluation is related to the formation or maintenance of hallucinations and delusions in schizophrenia.     

Specificity of emotion-related effects on attentional processing in schizotypy

OBJECTIVES: In the schizophrenia spectrum, cognitive functions such as perception, language, and attention have been shown to be adversely influenced by negative affect. The present study addressed three issues of specificity and one issue of mechanism regarding affect-related attentional disruption in schizotypy: (1) Is attentional disturbance from negative affective stimuli specific to positive (PS) but not negative schizotypy (NS)? (2) Do positive affective stimuli also foster attentional disturbance? (3) Are anxiety and depression differentially related to PS and NS? (4) Whatever the degree of specificity in these relationships, does anxiety mediate the relationship between schizotypy and attentional disturbance? METHODS: Nonpatient participants (N=162) provided responses on scales of schizotypy, anxiety, and depression and performed an emotional Stroop task, judging the ink color of positive, neutral, and negative words. RESULTS: PS but not NS was associated with poorer attentional performance. This attentional disturbance was specific to negative words. PS was associated with anxiety and depression, whereas NS was associated only with depression. Finally, anxiety and depression did not fully mediate the relationship between PS and attentional interference related to negative affective stimuli. CONCLUSIONS: Findings of attentional disturbance in the presence of negative affective stimuli, particularly in positive schizotypy, have substantial theoretical implications. They provide a path by which the interplay of cognitive and affective phenomena could lead to the formation, maintenance, and exacerbation of positive symptoms, including delusions and hallucinations. Findings from this study also underscore the importance of examining the differential contribution of comorbid anxiety and depression to cognitive and affective function in the schizophrenia spectrum.     

Cognitive neuroscience of delusions in aging

Assessments and clinical understanding of late-onset delusions in the elderly are inconsistent and often incomplete. In this review, we consider the prevalence, neurobehavioral features, and neuroanatomic correlations of delusions in elderly persons – those with documented cognitive decline and those with no evidence of cognitive decline. Both groups exhibit a common phenotype: delusions are either of persecution or of misidentification. Late-onset delusions show a nearly complete absence of the grandiose, mystical, or erotomanic content typical of early onset psychoses. Absent also from both elderly populations are formal thought disorders, thought insertions, and delusions of external control. Neuroimaging and behavioral studies suggest a frontotemporal localization of delusions in the elderly, with right hemispheric lateralization in delusional misidentification and left lateralization in delusions of persecution. We propose that delusions in the elderly reflect a common neuroanatomic and functional phenotype, and we discuss applications of our proposal to diagnosis and treatment.     

Persecutory delusions: a cybernetic model.

The authors propose a cybernetic model for the formation and maintenance of persecutory delusions. During the formation of persecutory ideation, the threat of loss of control over the self or others interacts with predictions of control from others. This interaction may result in feelings of alien control followed by persecutory explanations. Since the persecutory explanations provide the individual with a new goal of resisting others' influence in order to prevent being controlled, they reduce the threat of loss of self-control. This is how persecutory delusions are maintained.